Updated TurningPoint provider training guide now available

We’ve updated the TurningPoint Provider Training Guide to include:

  • Additional information requests (all plans)
  • Intent to deny calls (Medicare)
  • Reconsideration requests (commercial, Medicaid)

We made these updates to offer further transparency into TurningPoint’s processes, and to support you in getting the most accurate determination the first time and, if possible, avoid the appeals process.

As a reminder, TurningPoint manages cardiac and MSK authorizations on our members’ behalf.

Below is a summary of the additions made to the training guide, pages 20-22.

Requests for additional information

If additional information is required to make a determination on an authorization request, TurningPoint will reach out to the provider up to three times via a combination of phone and fax, within the designated turnaround timeframe for the case’s priority and plan type. You can find a copy of the request for information in TurningPoint’s provider portal.

Medicare intent to deny

Once an authorization request for a Medicare case has been denied, there isn’t an option available that could overturn the denial – appeal is the only avenue. Because of this, TurningPoint makes an Intent to Deny (ITD) call to the requesting provider ahead of a potential denial for Medicare cases.

During the ITD call, TurningPoint will help the provider take appropriate action to avoid an adverse decision by sharing:

  • Rationale for the potential adverse determination
  • Information about the option to schedule a peer-to-peer discussion before the final determination
  • When the case is set to deny if additional information isn’t received, or a pre-denial peer-to-peer isn’t scheduled

Reconsideration requests

For commercial and Medicaid cases that have been denied – partially or fully – the provider may request a reconsideration before filing an appeal. Reconsiderations:

  • Take additional information / documentation into account
  • Return a decision within 5 calendar days
  • May result in a revised determination without the need to proceed to an appeal.

A reconsideration can be a helpful step following a post-denial peer-to-peer review (P2P), though a P2P isn’t required to submit a reconsideration request. Note: Reconsiderations don’t always result in an approval.

Please see the updated TurningPoint Provider Training Guide (pages 19-22) for more details.